- Email: [email protected]
Understanding Lesbian Experience
can’t remember all the details of the experience because I wasn’t assigned to this woman and her partner that night shift. It was about eight to nine years ago. I do, however, remember the dynamics on the unit that evening. They were uncomfortable, disrespectful. I was working in the U.S. as a perinatal nurse in labor and childbirth. The couple was lesbian, although they didn’t overtly acknowledge this to their nurse. I understood why. Although many of
I What Perinatal Nurses Should Know to Promote Women’s Health Lisa Goldberg, RN, PhD
Photograph used with permission
my colleagues were respectful women and cared deeply about what they did as nurses, they were uncomfortable with lesbian experience. This discomfort revealed itself in a variety of ways: avoidance, inappropriateness, distance and modes of being that were not representative of the colleagues that I knew and often admired. What causes otherwise respectful, intelligent and caring nurses to exhibit behaviors that can diminish and devalue women who are already marginalized and invisible? Is it fear of the unknown, inability to understand difference, or general ignorance? I don’t claim to have the answers to these questions, but encouraging dialogue between nurses, other health care providers and the lesbian couples with whom we are privileged to work may help us understand our own behaviors and ultimately better understand ourselves. Only then will we be able to work in authentic relationships with lesbian couples that move us beyond the heterosexist and homophobic practices that permeate ourselves and the health care institutions in which we work. Why should perinatal nurses in clinical practice care about lesbian health? After all, isn’t lesbian health the same as women’s health? The answer is no. Although exact accounts of lesbian experience will not likely be obtained for fear of disclosure in homophobic environments, their lived experiences and ways of being in the world are different. Because of heterosexist and homophobic practices reflected in health care institutions, lesbians often fail to disclose important healthrelated information with their health care providers. As a result, treatment and diagnosis are compromised; access to care, advice and support are restricted (Platzer & James, 2000; Saulnier, 2002). Unlike heterosexual couples experiencing the joys of pregnancy and birth, lesbian couples often encounter discrimination, barriers to achieving pregnancy and the possibility of losing support from their family, friends and colleagues (Tash & Kenney, 1993). Lesbian couples have reported not disclosing their sexuality for fear that they would be considered “bad mothers” or that their parenting skills would be viewed under a microscope (Wilton & Kaufmann, 2001). Health care providers in the United Kingdom went so far as to turn one lesbian woman away from prenatal classes, and those who enrolled in prenatal classes elsewhere felt ignored and excluded by the heterosexist bias (Wilton & Kaufmann, 2001).
Homophobia and Heterosexism in Health Care Hospital environments are permeated with heterosexist bias and heteronormativity. Because the underlying assumption by many health care providers is that all women’s partners are Lisa S. Goldberg, RN, PhD, is an assistant professor at Dalhousie University, the School of Nursing, Halifax Nova Scotia. DOI: 10.1177/1091592305285271
464
AWHONN Lifelines
male, everything from the written forms to the posters on the wall represents this heterosexist bias (Stevens, 1995; Wilton & Kaufmann, 2001). The forms for women to document their personal and health histories leave no space to discuss relationships that are not heterosexual; birthing environments have no pictures or photos of lesbian couples. The only visual representation is heterosexual: a man and a woman. Being excluded from the heterosexual norm, lesbians and their partners fear ostracism, abuse, mistreatment and exclusion when entering the health care system (Platzer & James, 2000; Stevens, 1995; Wilton, 1999; Zeidenstein, 1990). Lesbians who self-disclosed, or “came out,” have reported experiencing the following when interacting with their health care providers (Hitchcock & Wilson, 1992; Stevens, 1994): • • • • •
rough procedures inappropriate behavior(s) demeaning responses voyeurism breached confidentiality
One lesbian couple actually reported that their child was placed on a “concern list” simply because of the nature of their relationship (Wilton & Kaufmann, 2001). Homophobia is a discriminatory practice and prejudice. It represents a fear of lesbians and gay men. It’s a learned and internalized behavior and can manifest itself as hatred, fear, ignorance and exclusion (Platzer & James, 2000; Wilton, 1999). Homophobia places a huge cost on society and has been linked to increased rates in smoking, alcohol use, depression, HIV/AIDS, physical violence and attempted suicide rates among members of the lesbian, gay, bisexual, transgendered and queer (LGBTQ) community (Banks, 2001, 2003). The impact of these health-related problems has been shown to place significant economic burden on the health care system (Banks, 2001, 2003). Heterosexism is the institutional assumption that heterosexuality is the norm for relationships; any variation is considered deviant. Those who engage in nonheterosexual relationships are discriminated against through the power of the heterosexual norm (Banks, 2003). Heterosexism is exacerbated by homophobia, which in turn can lead to abuse—verbal, nonverbal and physical (Mason & Palmer, 1996; Platzer & James, 2000). Heterosexist assumptions by health care providers make opening up about one’s sexuality both embarrassing and difficult for lesbians and their partners, particularly during vulnerable experiences like birth (Harvey, Carr, & Bernheine, 1989; Tash & Kenney, 1993). Widespread ignorance resulting from heterosexist assumptions by health care providers has resulted in mistakingly advising lesbians that they cannot contract a sexually transmitted infection from their female partner or that they do not require cervical cancer screening (Platzer & James, 2000). Evidence has shown that lesbians can have
Volume 9
Issue 6
abnormal pap tests even if they have never had sex with men (Bailey, 1997).
Lesbian Experience: Constructing Sameness and Difference Because not all women fall into the category of heterosexual, nurses must recognize that perinatal health care cannot be essentialized, or considered the same for each woman, particularly for a lesbian woman (McDonald, McIntyre, & Anderson, 2003). Although being lesbian is generally defined in terms of women whose affiliations, affections and sexual orientations are directed toward other women, research suggests that there is no universal lesbian experience or identity. The category of lesbian is contingent; it’s diversely constructed and historically situated (Ponse, 1978; Stevens & Hall, 1988). A further example of diversity found in lesbian experience is revealed in the writings of Rich (1986), a lesbian feminist author who challenges us to redefine lesbian experience. In so doing, we are asked to understand lesbian existence on a continuum, independent of whether we situate ourselves within the lesbian community or not. Rich states, It’s with purpose that the terms lesbian existence and lesbian continuum are used because the word lesbianism has a clinical and limiting ring. Lesbian existence suggests both the fact of the historical presence of lesbians and our continuing creation of the meaning of that existence. The term lesbian continuum is meant to include a range—through each woman’s life and throughout history—of woman-identified experience, not simply the fact that a woman has had or consciously desired genital sexual experience with another woman. (p. 51)
n esbia ing L d n a rst Unde nce rie e p x E lized in e argina nd th eel m f s le are, a coup atal c n in ia r are e b s s p Le ts of ovider aspec are pr c y n h a lt m . hea es of for this attitud onsible p s e r ly tional direct he institu e h t ty is t xism is eterosexuali e is s o n r e io Het at h variat tion th ; any p s m ip u h s s as tion for rela . y norm eviant d inator d ere iscrim d a d consid e s t n a lear presen hat re t obia is h e p ic o Hom . prejud y men e and nd ga a practic s n ia f lesb fear o
December 2005 | January 2006
Rich’s (1986) reference to the lesbian continuum reminds us of new possibilities for lesbian experience: a way to move beyond the traditional binary of the heterosexual/homosexual divide. Independent of whether we interpret lesbian experience on a continuum or as a category, our experiences as perinatal nurses are as diverse as the women in our care. To this end, our sexuality may also be lesbian, bisexual or heterosexual.
Listening to the Research Perinatal nurses have both a professional and moral responsibility to treat all women (Canadian Nurses Association, 1997), including lesbians and their partners, with dignity and respect, advocating for health care services on their behalf. Although no published research currently exists examining lesbian couples in their relationships with perinatal nurses, the general research in lesbian health may provide some helpful strategies for perinatal nurses working with lesbian couples during their experiences of birth. Of note, a three-year feminist phenomenological study has recently been funded by the Nova Scotia Health Research foundation exploring the multiple realities of lesbian couples in their birthing relations with perinatal nurses. The team of investigators from Dalhousie University includes L. Goldberg, B. Frank, J. Evans, S. Campbell, and research assistant T. Keener. Within the literature, it was noted that having a family physician who was “gay positive,” that is, someone who was open, knowledgeable and comfortable with sexual difference, was one of the best ways that a health care provider could respect lesbian experience (Mathieson, 1998). This not only created a safe space for lesbians and their partners to disclose information, it further illustrated the ways in which a health care provider attempted to understand the meaning of being lesbian in a world outside of the health care encounter. In so doing, the health care provider recognized the invisibility, fear and homophobia lesbians experience in their daily lives. A number of strategies to promote a gay-positive environment derived from the lesbian and bisexual women who participated in Mathieson’s (1998) study, included finding a family physician who was aware of her or his own biases and possessed a willingness to educate herself or himself in the process of understanding lesbian experience. A further suggestion made by the women participants related to how health histories were currently being done. Taking heterosexism seriously means reevaluating the ways in which health histories are performed. This entails reassessing how we ask questions as health care providers. It was suggested that questions such as “Are you presently in a relationship?” or “Who is your partner in your relationship?” were more appropriate ways of acknowledging the relationship status of a woman entering the health care system (Mathieson, 1998). Providing a safe environment that validates lesbian experience was also considered a strategy for signaling a gay-positive
AWHONN Lifelines
465
environment. This recommendation can be achieved by establishing a health care facility that has pictures of lesbian couples on the walls, pamphlets of lesbian and bisexual health readily available, and health care providers who are knowledgeable regarding the health care needs of lesbians and bisexual women (Mathieson, 1998). In “Lesbian Mothers’ Experiences of Maternity Care in the UK,” Wilton and Kaufmann (2001) documented lesbian mothers’ experiences of their midwives during maternity care. The recommendations included: • having health care providers recognize the significance of a lesbian partnership • acknowledging that each couple was not the only lesbian couple to ever have a baby • encouraging health care providers to use the word “lesbian” in their clinical practice Because lesbian couples are not the majority of couples having babies, health care providers became uncomfortable in addressing sexual difference. Caution, however, must be taken when using euphemisms, as they were shown in this study to be considered offensive. Words like “special friend” or “friend” were not thought appropriate when addressing the parent of a child. Most of the women who participated in the study simply wanted to be valued and recognized as a lesbian mother. This begins by providing an open and honest relationship and can be facilitated by simply asking a lesbian couple how they would like to be addressed (Wilton & Kaufmann, 2001). Recognizing the importance of establishing respectful and open relationships with lesbian couples, Goldberg (2005) explored the importance of the gaze, the touch and the breath in the introductory moments of birthing care. Although her research was not specific to lesbian experience, she recognized how the introductory moments of care nurture our future relationships with all birthing women. If these crucial moments of care are negated, we disengage from relationship and disregard the particulars of women’s lives (Goldberg, 2005). Although lesbians have unique identities and look and act like other women, their relationships are often thwarted by homophobic and heterosexist practices (Simkin, 1993). Regrettably, this is not surprising when we consider what the health research indicates. For example, in a 1991 (Eliason & Randall) study on lesbian phobia with nursing students, 50 percent of the student nurse participants felt that living as a lesbian was an unacceptable lifestyle. Of those respondents, 15 percent believed that there should be laws prohibiting sexual relationships between lesbians. A further result from the study revealed that 28 percent of the nursing students thought lesbians were in a high-risk group for AIDS, independent of the fact that the same students had education situating lesbians in a low-risk group for contracting AIDS.
466
AWHONN Lifelines
What this seemed to suggest, according to the researchers, was that the nursing students disregarded their education and associated all “gay life-styles with AIDS” (Eliason & Randall, 1991, p. 371). Lesbian phobia is multilayered; it perpetuates negativity, avoidance, invisibility and stereotypes (Eliason & Randall, 1991).
Improving Health Care for Lesbians To counter these issues and improve conditions, particularly within nursing education, the researchers recommended the following: • Inclusiveness: Include the lesbian community in its relevant context. Provide ways of broadening the current nursing and health care curriculum by using guest speakers, workshops and textbooks that offer diverse and thoughtful interpretations of alternative and healthy, not deviant, lifestyles • Clinical Placements: Provide clinical opportunities for students to work with the lesbian community. Additionally, role-playing should be provided for students to practice working with lesbian clients. The students should learn to recognize their heterosexual assumptions and how their interactions might be different when they don’t assume that all clients are heterosexual • Confronting Own Biases: To integrate lesbianism as a healthy and alternative lifestyle into nursing curriculum, nursing education and nursing practice, it’s essential that nursing faculty and nursing leaders examine their own biases and “confront their own homophobia and examine the negative stereotypes they hold about lesbians” (Eliason & Randall, 1991, p. 372) Although the research by Eliason and Randall (1991) was conducted 14 years ago, little has changed. In a qualitative research study examining why lesbians resisted disclosing their sexual orientation with their health care providers, Barbara, Quandt, and Anderson (2001) revealed that homophobic and heterosexist practices prevented many of their participants from sharing their lesbian identities with their health care providers. Feelings of anxiety, fear of humiliation and heterosexist stereotypes were some of the concerns expressed by the women. Deciding weather or not to disclose their sexual orientation with their health care providers was largely based on their perceptions of their provider’s comfort with homosexuality. Some of the strategies suggested by the researchers to address homophobia and work with their lesbian clients in the workplace included (Barbara et al., 2001): • educating staff about lesbian health and sexual diversity • eliminating anti-lesbian/gay behaviors and creating an environment of acceptance and inclusiveness • revising standardized forms to be inclusive of sexual diversity
Volume 9
Issue 6
• welcoming lesbian clients in partnerships in the same ways that heterosexual clients in partnerships are welcomed To recognize the extent to which homophobia and heterosexism permeate perinatal nursing practice, and understand their effects on lesbian couples within the context of care, we must revise the very nature of our current health care practices and polices. Beginning with our educational institutions and how we educate nurses, to the health care environments in which we work, issues related to the lesbian, gay, bisexual and transgendered (LGBT) community must become an integral part of our daily lives. From the policies that guide perinatal practices to the visual images that hang on the walls of our health care institutions, lesbians and their partners must have equal representation. Only then will perinatal nurses and other health care providers be able to work in authentic relationships with lesbian couples that move beyond the heterosexist and homophobic practices that permeate both ourselves and the health care facilities in which we work.
Box 1.
Get the Facts • National Coalition For Lesbian, Gay, Bisexual and Transgender Health: www.lgbthealth.net • Gay and Lesbian Medical Association: www.glma.org • Lgbthealth channel: http://gayhealthchannel.com/ • Proudparenting.com • Egale Canada: http://www.egale.ca/index.asp?lang=E • Canadian Rainbow Health Coalition: www.rainbowhealth.ca
References Bailey, J.(1997). Sexual health for women who have sex with women. Women’s Health, 2(3), 9-10. Banks, C. (2001). The cost of homophobia: Literature review of economic impact of homophobia on Canada. Saskatoon, SK: Rochon Associated Human Resource Management Consulting. Banks, C. (2003). The cost of homophobia: Literature review on the human impact of homophobia in Canada. Saskatoon, SK: Rochon Associated Human Resource Management Consulting. Barbara, A. M., Quandt, S. A., & Anderson, R. T. (2001). Experiences of lesbians in the health care environment. Women & Health, 34(1), 45-62. Canadian Nurses Association. (1997). Code of ethics for registered nurses. Ottawa: Author.
December 2005 | January 2006
Eliason, M. J., & Randall, C. E. (1991). Lesbian phobia in nursing students. Western Journal of Nursing Research, 13(3), 363-374. Goldberg, L. (2005). Introductory engagement within the perinatal nursing relationship. Nursing Ethics, 12(4), 401-413. Harvey, S. M., Carr, C. & Bernheine, S. (1989). Lesbian mothers health care experiences. Journal of Nurse-Midwifery, 34(3), 115-119. Hitchcock, J. M., & Wilson, H. S. (1992). Personal risking: Lesbian self-disclosure of sexual orientation to professional health care providers. Nursing Research, 41(3), 178-183. McDonald, C., McIntyre, M., & Anderson, B. (2003). The view from somewhere: Locating lesbian experience in women’s health. Health Care for Women International, 24, 697-711. Mason, A., & Palmer, A. (1996). Queerbashing: A national survey of hate crimes against lesbians and gay men. London: Stonewall. Mathieson, C. M. (1998). Lesbian and bisexual health care: Straight talk about experiences with physicians. Canadian Family Physicians, 44, 1634-1639. Platzer, H., & James, T. (2000). Lesbians’ experiences of healthcare. Nursing Times Research, 5(3), 194-202. Ponse, B. (1978). Identities in the lesbian world: The social construction of self. Westport, CT: Greenwood. Rich, A. (1986). Compulsory heterosexuality and lesbian existence. In A. Rich (Ed.), Blood, bread and poetry: Selected prose 1979-1985 (pp. 23-75). New York: Norton. Saulnier, C. F. (2002). Deciding who to see: Lesbians discuss their preferences in health and mental health care. Social Work, 47(4), 355-365. Simkin, R. J. (1993). Unique health care concerns of lesbians. Canadian Journal of Ob/Gyn and Women’s Health Care, 5(5), 516-522. Stevens, P. E. (1994). Protective strategies of lesbian clients in health care environments. Research in Nursing & Health, 17, 217-229. Stevens, P. E. (1995). Structural and interpersonal impact of heterosexual assumptions on lesbian health care clients. Nursing Research, 44(1), 25-30. Stevens, P. E., & Hall, J. M. (1988). Stigma, health beliefs and experiences with health care in lesbian women. Image: Journal of Nursing Scholarship, 20(2), 69-73. Tash, T. T., & Kenney, W. (1993). The lesbian childbearing couple: A case study. Birth, 20(1), 36-40. Wilton, T. (1999). Towards an understanding of the cultural roots of homophobia in order to provide a better midwifery service for lesbian clients. Midwifery, 15, 154-164. Wilton, T., & Kaufmann, T. (2001). Lesbian mothers’ experiences of maternity care in the UK. Midwifery, 17, 203-211. Zeidenstein, L. (1990). Gynecological and childbearing needs of lesbians. Journal of Nurse-Midwifery, 35(1), 10-18.
AWHONN Lifelines
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I What Perinatal Nurses Should Know to Promote Women’s Health Lisa Goldberg, RN, PhD
Photograph used with permission
my colleagues were respectful women and cared deeply about what they did as nurses, they were uncomfortable with lesbian experience. This discomfort revealed itself in a variety of ways: avoidance, inappropriateness, distance and modes of being that were not representative of the colleagues that I knew and often admired. What causes otherwise respectful, intelligent and caring nurses to exhibit behaviors that can diminish and devalue women who are already marginalized and invisible? Is it fear of the unknown, inability to understand difference, or general ignorance? I don’t claim to have the answers to these questions, but encouraging dialogue between nurses, other health care providers and the lesbian couples with whom we are privileged to work may help us understand our own behaviors and ultimately better understand ourselves. Only then will we be able to work in authentic relationships with lesbian couples that move us beyond the heterosexist and homophobic practices that permeate ourselves and the health care institutions in which we work. Why should perinatal nurses in clinical practice care about lesbian health? After all, isn’t lesbian health the same as women’s health? The answer is no. Although exact accounts of lesbian experience will not likely be obtained for fear of disclosure in homophobic environments, their lived experiences and ways of being in the world are different. Because of heterosexist and homophobic practices reflected in health care institutions, lesbians often fail to disclose important healthrelated information with their health care providers. As a result, treatment and diagnosis are compromised; access to care, advice and support are restricted (Platzer & James, 2000; Saulnier, 2002). Unlike heterosexual couples experiencing the joys of pregnancy and birth, lesbian couples often encounter discrimination, barriers to achieving pregnancy and the possibility of losing support from their family, friends and colleagues (Tash & Kenney, 1993). Lesbian couples have reported not disclosing their sexuality for fear that they would be considered “bad mothers” or that their parenting skills would be viewed under a microscope (Wilton & Kaufmann, 2001). Health care providers in the United Kingdom went so far as to turn one lesbian woman away from prenatal classes, and those who enrolled in prenatal classes elsewhere felt ignored and excluded by the heterosexist bias (Wilton & Kaufmann, 2001).
Homophobia and Heterosexism in Health Care Hospital environments are permeated with heterosexist bias and heteronormativity. Because the underlying assumption by many health care providers is that all women’s partners are Lisa S. Goldberg, RN, PhD, is an assistant professor at Dalhousie University, the School of Nursing, Halifax Nova Scotia. DOI: 10.1177/1091592305285271
464
AWHONN Lifelines
male, everything from the written forms to the posters on the wall represents this heterosexist bias (Stevens, 1995; Wilton & Kaufmann, 2001). The forms for women to document their personal and health histories leave no space to discuss relationships that are not heterosexual; birthing environments have no pictures or photos of lesbian couples. The only visual representation is heterosexual: a man and a woman. Being excluded from the heterosexual norm, lesbians and their partners fear ostracism, abuse, mistreatment and exclusion when entering the health care system (Platzer & James, 2000; Stevens, 1995; Wilton, 1999; Zeidenstein, 1990). Lesbians who self-disclosed, or “came out,” have reported experiencing the following when interacting with their health care providers (Hitchcock & Wilson, 1992; Stevens, 1994): • • • • •
rough procedures inappropriate behavior(s) demeaning responses voyeurism breached confidentiality
One lesbian couple actually reported that their child was placed on a “concern list” simply because of the nature of their relationship (Wilton & Kaufmann, 2001). Homophobia is a discriminatory practice and prejudice. It represents a fear of lesbians and gay men. It’s a learned and internalized behavior and can manifest itself as hatred, fear, ignorance and exclusion (Platzer & James, 2000; Wilton, 1999). Homophobia places a huge cost on society and has been linked to increased rates in smoking, alcohol use, depression, HIV/AIDS, physical violence and attempted suicide rates among members of the lesbian, gay, bisexual, transgendered and queer (LGBTQ) community (Banks, 2001, 2003). The impact of these health-related problems has been shown to place significant economic burden on the health care system (Banks, 2001, 2003). Heterosexism is the institutional assumption that heterosexuality is the norm for relationships; any variation is considered deviant. Those who engage in nonheterosexual relationships are discriminated against through the power of the heterosexual norm (Banks, 2003). Heterosexism is exacerbated by homophobia, which in turn can lead to abuse—verbal, nonverbal and physical (Mason & Palmer, 1996; Platzer & James, 2000). Heterosexist assumptions by health care providers make opening up about one’s sexuality both embarrassing and difficult for lesbians and their partners, particularly during vulnerable experiences like birth (Harvey, Carr, & Bernheine, 1989; Tash & Kenney, 1993). Widespread ignorance resulting from heterosexist assumptions by health care providers has resulted in mistakingly advising lesbians that they cannot contract a sexually transmitted infection from their female partner or that they do not require cervical cancer screening (Platzer & James, 2000). Evidence has shown that lesbians can have
Volume 9
Issue 6
abnormal pap tests even if they have never had sex with men (Bailey, 1997).
Lesbian Experience: Constructing Sameness and Difference Because not all women fall into the category of heterosexual, nurses must recognize that perinatal health care cannot be essentialized, or considered the same for each woman, particularly for a lesbian woman (McDonald, McIntyre, & Anderson, 2003). Although being lesbian is generally defined in terms of women whose affiliations, affections and sexual orientations are directed toward other women, research suggests that there is no universal lesbian experience or identity. The category of lesbian is contingent; it’s diversely constructed and historically situated (Ponse, 1978; Stevens & Hall, 1988). A further example of diversity found in lesbian experience is revealed in the writings of Rich (1986), a lesbian feminist author who challenges us to redefine lesbian experience. In so doing, we are asked to understand lesbian existence on a continuum, independent of whether we situate ourselves within the lesbian community or not. Rich states, It’s with purpose that the terms lesbian existence and lesbian continuum are used because the word lesbianism has a clinical and limiting ring. Lesbian existence suggests both the fact of the historical presence of lesbians and our continuing creation of the meaning of that existence. The term lesbian continuum is meant to include a range—through each woman’s life and throughout history—of woman-identified experience, not simply the fact that a woman has had or consciously desired genital sexual experience with another woman. (p. 51)
n esbia ing L d n a rst Unde nce rie e p x E lized in e argina nd th eel m f s le are, a coup atal c n in ia r are e b s s p Le ts of ovider aspec are pr c y n h a lt m . hea es of for this attitud onsible p s e r ly tional direct he institu e h t ty is t xism is eterosexuali e is s o n r e io Het at h variat tion th ; any p s m ip u h s s as tion for rela . y norm eviant d inator d ere iscrim d a d consid e s t n a lear presen hat re t obia is h e p ic o Hom . prejud y men e and nd ga a practic s n ia f lesb fear o
December 2005 | January 2006
Rich’s (1986) reference to the lesbian continuum reminds us of new possibilities for lesbian experience: a way to move beyond the traditional binary of the heterosexual/homosexual divide. Independent of whether we interpret lesbian experience on a continuum or as a category, our experiences as perinatal nurses are as diverse as the women in our care. To this end, our sexuality may also be lesbian, bisexual or heterosexual.
Listening to the Research Perinatal nurses have both a professional and moral responsibility to treat all women (Canadian Nurses Association, 1997), including lesbians and their partners, with dignity and respect, advocating for health care services on their behalf. Although no published research currently exists examining lesbian couples in their relationships with perinatal nurses, the general research in lesbian health may provide some helpful strategies for perinatal nurses working with lesbian couples during their experiences of birth. Of note, a three-year feminist phenomenological study has recently been funded by the Nova Scotia Health Research foundation exploring the multiple realities of lesbian couples in their birthing relations with perinatal nurses. The team of investigators from Dalhousie University includes L. Goldberg, B. Frank, J. Evans, S. Campbell, and research assistant T. Keener. Within the literature, it was noted that having a family physician who was “gay positive,” that is, someone who was open, knowledgeable and comfortable with sexual difference, was one of the best ways that a health care provider could respect lesbian experience (Mathieson, 1998). This not only created a safe space for lesbians and their partners to disclose information, it further illustrated the ways in which a health care provider attempted to understand the meaning of being lesbian in a world outside of the health care encounter. In so doing, the health care provider recognized the invisibility, fear and homophobia lesbians experience in their daily lives. A number of strategies to promote a gay-positive environment derived from the lesbian and bisexual women who participated in Mathieson’s (1998) study, included finding a family physician who was aware of her or his own biases and possessed a willingness to educate herself or himself in the process of understanding lesbian experience. A further suggestion made by the women participants related to how health histories were currently being done. Taking heterosexism seriously means reevaluating the ways in which health histories are performed. This entails reassessing how we ask questions as health care providers. It was suggested that questions such as “Are you presently in a relationship?” or “Who is your partner in your relationship?” were more appropriate ways of acknowledging the relationship status of a woman entering the health care system (Mathieson, 1998). Providing a safe environment that validates lesbian experience was also considered a strategy for signaling a gay-positive
AWHONN Lifelines
465
environment. This recommendation can be achieved by establishing a health care facility that has pictures of lesbian couples on the walls, pamphlets of lesbian and bisexual health readily available, and health care providers who are knowledgeable regarding the health care needs of lesbians and bisexual women (Mathieson, 1998). In “Lesbian Mothers’ Experiences of Maternity Care in the UK,” Wilton and Kaufmann (2001) documented lesbian mothers’ experiences of their midwives during maternity care. The recommendations included: • having health care providers recognize the significance of a lesbian partnership • acknowledging that each couple was not the only lesbian couple to ever have a baby • encouraging health care providers to use the word “lesbian” in their clinical practice Because lesbian couples are not the majority of couples having babies, health care providers became uncomfortable in addressing sexual difference. Caution, however, must be taken when using euphemisms, as they were shown in this study to be considered offensive. Words like “special friend” or “friend” were not thought appropriate when addressing the parent of a child. Most of the women who participated in the study simply wanted to be valued and recognized as a lesbian mother. This begins by providing an open and honest relationship and can be facilitated by simply asking a lesbian couple how they would like to be addressed (Wilton & Kaufmann, 2001). Recognizing the importance of establishing respectful and open relationships with lesbian couples, Goldberg (2005) explored the importance of the gaze, the touch and the breath in the introductory moments of birthing care. Although her research was not specific to lesbian experience, she recognized how the introductory moments of care nurture our future relationships with all birthing women. If these crucial moments of care are negated, we disengage from relationship and disregard the particulars of women’s lives (Goldberg, 2005). Although lesbians have unique identities and look and act like other women, their relationships are often thwarted by homophobic and heterosexist practices (Simkin, 1993). Regrettably, this is not surprising when we consider what the health research indicates. For example, in a 1991 (Eliason & Randall) study on lesbian phobia with nursing students, 50 percent of the student nurse participants felt that living as a lesbian was an unacceptable lifestyle. Of those respondents, 15 percent believed that there should be laws prohibiting sexual relationships between lesbians. A further result from the study revealed that 28 percent of the nursing students thought lesbians were in a high-risk group for AIDS, independent of the fact that the same students had education situating lesbians in a low-risk group for contracting AIDS.
466
AWHONN Lifelines
What this seemed to suggest, according to the researchers, was that the nursing students disregarded their education and associated all “gay life-styles with AIDS” (Eliason & Randall, 1991, p. 371). Lesbian phobia is multilayered; it perpetuates negativity, avoidance, invisibility and stereotypes (Eliason & Randall, 1991).
Improving Health Care for Lesbians To counter these issues and improve conditions, particularly within nursing education, the researchers recommended the following: • Inclusiveness: Include the lesbian community in its relevant context. Provide ways of broadening the current nursing and health care curriculum by using guest speakers, workshops and textbooks that offer diverse and thoughtful interpretations of alternative and healthy, not deviant, lifestyles • Clinical Placements: Provide clinical opportunities for students to work with the lesbian community. Additionally, role-playing should be provided for students to practice working with lesbian clients. The students should learn to recognize their heterosexual assumptions and how their interactions might be different when they don’t assume that all clients are heterosexual • Confronting Own Biases: To integrate lesbianism as a healthy and alternative lifestyle into nursing curriculum, nursing education and nursing practice, it’s essential that nursing faculty and nursing leaders examine their own biases and “confront their own homophobia and examine the negative stereotypes they hold about lesbians” (Eliason & Randall, 1991, p. 372) Although the research by Eliason and Randall (1991) was conducted 14 years ago, little has changed. In a qualitative research study examining why lesbians resisted disclosing their sexual orientation with their health care providers, Barbara, Quandt, and Anderson (2001) revealed that homophobic and heterosexist practices prevented many of their participants from sharing their lesbian identities with their health care providers. Feelings of anxiety, fear of humiliation and heterosexist stereotypes were some of the concerns expressed by the women. Deciding weather or not to disclose their sexual orientation with their health care providers was largely based on their perceptions of their provider’s comfort with homosexuality. Some of the strategies suggested by the researchers to address homophobia and work with their lesbian clients in the workplace included (Barbara et al., 2001): • educating staff about lesbian health and sexual diversity • eliminating anti-lesbian/gay behaviors and creating an environment of acceptance and inclusiveness • revising standardized forms to be inclusive of sexual diversity
Volume 9
Issue 6
• welcoming lesbian clients in partnerships in the same ways that heterosexual clients in partnerships are welcomed To recognize the extent to which homophobia and heterosexism permeate perinatal nursing practice, and understand their effects on lesbian couples within the context of care, we must revise the very nature of our current health care practices and polices. Beginning with our educational institutions and how we educate nurses, to the health care environments in which we work, issues related to the lesbian, gay, bisexual and transgendered (LGBT) community must become an integral part of our daily lives. From the policies that guide perinatal practices to the visual images that hang on the walls of our health care institutions, lesbians and their partners must have equal representation. Only then will perinatal nurses and other health care providers be able to work in authentic relationships with lesbian couples that move beyond the heterosexist and homophobic practices that permeate both ourselves and the health care facilities in which we work.
Box 1.
Get the Facts • National Coalition For Lesbian, Gay, Bisexual and Transgender Health: www.lgbthealth.net • Gay and Lesbian Medical Association: www.glma.org • Lgbthealth channel: http://gayhealthchannel.com/ • Proudparenting.com • Egale Canada: http://www.egale.ca/index.asp?lang=E • Canadian Rainbow Health Coalition: www.rainbowhealth.ca
References Bailey, J.(1997). Sexual health for women who have sex with women. Women’s Health, 2(3), 9-10. Banks, C. (2001). The cost of homophobia: Literature review of economic impact of homophobia on Canada. Saskatoon, SK: Rochon Associated Human Resource Management Consulting. Banks, C. (2003). The cost of homophobia: Literature review on the human impact of homophobia in Canada. Saskatoon, SK: Rochon Associated Human Resource Management Consulting. Barbara, A. M., Quandt, S. A., & Anderson, R. T. (2001). Experiences of lesbians in the health care environment. Women & Health, 34(1), 45-62. Canadian Nurses Association. (1997). Code of ethics for registered nurses. Ottawa: Author.
December 2005 | January 2006
Eliason, M. J., & Randall, C. E. (1991). Lesbian phobia in nursing students. Western Journal of Nursing Research, 13(3), 363-374. Goldberg, L. (2005). Introductory engagement within the perinatal nursing relationship. Nursing Ethics, 12(4), 401-413. Harvey, S. M., Carr, C. & Bernheine, S. (1989). Lesbian mothers health care experiences. Journal of Nurse-Midwifery, 34(3), 115-119. Hitchcock, J. M., & Wilson, H. S. (1992). Personal risking: Lesbian self-disclosure of sexual orientation to professional health care providers. Nursing Research, 41(3), 178-183. McDonald, C., McIntyre, M., & Anderson, B. (2003). The view from somewhere: Locating lesbian experience in women’s health. Health Care for Women International, 24, 697-711. Mason, A., & Palmer, A. (1996). Queerbashing: A national survey of hate crimes against lesbians and gay men. London: Stonewall. Mathieson, C. M. (1998). Lesbian and bisexual health care: Straight talk about experiences with physicians. Canadian Family Physicians, 44, 1634-1639. Platzer, H., & James, T. (2000). Lesbians’ experiences of healthcare. Nursing Times Research, 5(3), 194-202. Ponse, B. (1978). Identities in the lesbian world: The social construction of self. Westport, CT: Greenwood. Rich, A. (1986). Compulsory heterosexuality and lesbian existence. In A. Rich (Ed.), Blood, bread and poetry: Selected prose 1979-1985 (pp. 23-75). New York: Norton. Saulnier, C. F. (2002). Deciding who to see: Lesbians discuss their preferences in health and mental health care. Social Work, 47(4), 355-365. Simkin, R. J. (1993). Unique health care concerns of lesbians. Canadian Journal of Ob/Gyn and Women’s Health Care, 5(5), 516-522. Stevens, P. E. (1994). Protective strategies of lesbian clients in health care environments. Research in Nursing & Health, 17, 217-229. Stevens, P. E. (1995). Structural and interpersonal impact of heterosexual assumptions on lesbian health care clients. Nursing Research, 44(1), 25-30. Stevens, P. E., & Hall, J. M. (1988). Stigma, health beliefs and experiences with health care in lesbian women. Image: Journal of Nursing Scholarship, 20(2), 69-73. Tash, T. T., & Kenney, W. (1993). The lesbian childbearing couple: A case study. Birth, 20(1), 36-40. Wilton, T. (1999). Towards an understanding of the cultural roots of homophobia in order to provide a better midwifery service for lesbian clients. Midwifery, 15, 154-164. Wilton, T., & Kaufmann, T. (2001). Lesbian mothers’ experiences of maternity care in the UK. Midwifery, 17, 203-211. Zeidenstein, L. (1990). Gynecological and childbearing needs of lesbians. Journal of Nurse-Midwifery, 35(1), 10-18.
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